"Eventually, the cosmologists assure us, our sun and all suns will consume their fuel, violently explode and then become cold and dark. Matter itself will evaporate into the void and the universe will become desolate for the rest of time. ... (Read the rest)-Wes
Monday, August 26, 2013
On Sabbatical
I will be sparsely interacting with the internet as I take my last child off to college this week. It's a strange time - one where the home becomes more quiet as a moment ends for the parent yet heralds and exciting beginning for their child. Others have recently articulated this strange time well, so I leave you with the words of a much better writer, Michael Gerson of the Washington Post:
Saturday, August 24, 2013
The Cloudy Aspects of the Physician Payment Sunshine Act
Another seemingly harmless bureaucratic initiative aimed at physicians sunk its taproot deep in the daily workings of medicine this month. The Physician Payment Sunshine Act promises transparency in all industry dealings with physicians by shedding "light" on the issue of payments to physicians from pharmaceutical companies and medical device manufacturers. In turn, it will save the system money, since all those freebies bestowed upon physicians when the corporate world came knocking can now be accounted for and physicians will be shamed into proper behavior.
Meanwhile, back at the drug company headquarters, some poor schnook gets to type all the names of the nurses and technicians that enjoyed their meal from the echo lab, cath lab, stress testing lab and were asked to place their name on a sign-in list so it can be entered on a multi-million dollar database designed to feed the government Big Data Bosom in the sky. Busy doctors dart in, grab a bite, and go.
No need for them to sign-in.
You see, it's a bad marketing strategy to ask a doctor to sign a form as you peddle your product. And since no one is monitoring the accuracy of the sign-in sheets, as they have a few names to justify their effort and expense, well, they've done their part.
Why is this expensive data collection charade taking place? How much does it cost us? Does it change pharmaceutical tactics for marketing to doctors? Of course not. Yet there remain central planners who remain convinced (I mean, convinced!) that such monitoring works. It's a classic wish: just like the government's new HospitalCompare website, which promises to collect data on readmission, pneumonia, infection and death rates (with more to come) in the hopes that people will make "smart choices" about their health care. Do people really make their choice of health care facility based on such poorly-collected data placed on a website? I don't think so. Most people never think about their health until they have to arrive in an Emergency Room blindsided by an unexpected health crisis. They are not checking websites about payments to doctors - especially websites set up by the government. They want access to their local health care system and prompt, quality care. Yet were we are once again using Big Data filled with Bad Data as an ill-conceived and expensive social engineering exercise. And this cost is passed on to health care consumers. In short, it's another perfect storm of wasted resources in the practice of medicine.
"But Dr. Wes, how can you say such a thing? Can't you see this Sunshine Act developed by Congress as part of the Affordable Care Act will disclose all of those greedy physicians who want to suck the health care system dry of all of that money? Aren't there benefits to the public transparency of these payments?"
The irony of this whole law is that Big Pharma and Big Medical Device Company already reports the money they give doctors to the government via the IRS in the form of a 1099-Misc. (Recall that the IRS is now firmly a part of our new health care law). But instead of looking deep within the bureaucratic governmental morass for solutions to physician payments from industry, a new knee-jerk law was enacted to parade before the press to show how sincere the medical device companies and pharmaceutical companies are about the need for such transparency. Meanwhile, it's business as usual as backroom pricing of drugs and devices continues.
War room strategists have known this policy tactic for years: it's called diversion: collect data on every $20 dollar physician lunch handout as our new breed of physician-employers (aka "Accountable Care Organizations) negotiate sweet deals with their insurance pals, prices of hospital system charge masters edge ever higher, drug prices and device charges continue to exceed tens of thousands of dollars thanks to Medicare payments, and insurance companies offer "health plans" rather than "insurance" to their policy holders. And let's not even talk about the favors our Congressmen and Congresswomen are afforded.
But then again, better to put doctors in the limelight rather than speak honestly of the pricing games taking place behind American's backs, right?
-Wes
Meanwhile, back at the drug company headquarters, some poor schnook gets to type all the names of the nurses and technicians that enjoyed their meal from the echo lab, cath lab, stress testing lab and were asked to place their name on a sign-in list so it can be entered on a multi-million dollar database designed to feed the government Big Data Bosom in the sky. Busy doctors dart in, grab a bite, and go.
No need for them to sign-in.
You see, it's a bad marketing strategy to ask a doctor to sign a form as you peddle your product. And since no one is monitoring the accuracy of the sign-in sheets, as they have a few names to justify their effort and expense, well, they've done their part.
Why is this expensive data collection charade taking place? How much does it cost us? Does it change pharmaceutical tactics for marketing to doctors? Of course not. Yet there remain central planners who remain convinced (I mean, convinced!) that such monitoring works. It's a classic wish: just like the government's new HospitalCompare website, which promises to collect data on readmission, pneumonia, infection and death rates (with more to come) in the hopes that people will make "smart choices" about their health care. Do people really make their choice of health care facility based on such poorly-collected data placed on a website? I don't think so. Most people never think about their health until they have to arrive in an Emergency Room blindsided by an unexpected health crisis. They are not checking websites about payments to doctors - especially websites set up by the government. They want access to their local health care system and prompt, quality care. Yet were we are once again using Big Data filled with Bad Data as an ill-conceived and expensive social engineering exercise. And this cost is passed on to health care consumers. In short, it's another perfect storm of wasted resources in the practice of medicine.
"But Dr. Wes, how can you say such a thing? Can't you see this Sunshine Act developed by Congress as part of the Affordable Care Act will disclose all of those greedy physicians who want to suck the health care system dry of all of that money? Aren't there benefits to the public transparency of these payments?"
The irony of this whole law is that Big Pharma and Big Medical Device Company already reports the money they give doctors to the government via the IRS in the form of a 1099-Misc. (Recall that the IRS is now firmly a part of our new health care law). But instead of looking deep within the bureaucratic governmental morass for solutions to physician payments from industry, a new knee-jerk law was enacted to parade before the press to show how sincere the medical device companies and pharmaceutical companies are about the need for such transparency. Meanwhile, it's business as usual as backroom pricing of drugs and devices continues.
War room strategists have known this policy tactic for years: it's called diversion: collect data on every $20 dollar physician lunch handout as our new breed of physician-employers (aka "Accountable Care Organizations) negotiate sweet deals with their insurance pals, prices of hospital system charge masters edge ever higher, drug prices and device charges continue to exceed tens of thousands of dollars thanks to Medicare payments, and insurance companies offer "health plans" rather than "insurance" to their policy holders. And let's not even talk about the favors our Congressmen and Congresswomen are afforded.
But then again, better to put doctors in the limelight rather than speak honestly of the pricing games taking place behind American's backs, right?
-Wes
Wednesday, August 21, 2013
Why Do I Try So Hard?
It's always the same: It's the fifth hour of the procedure. As your ankles ache and the perspiration drips beneath your lead, you stand there wondering why you try so hard to fix this arrhythmia. You realize this is not cost effective. You're tying up the lab. The staff and anesthesiologist are getting restless. The music drones on. You feel you're not getting anywhere. "Then again, maybe if I just try this...," you think. And you try this and it fails. Meanwhile, the fluoroscopy clock ticks, your fight continues.
Then you remember the story: the syncope, the wife, the kids, the vocation. They're depending on you. Not a tech, not an anesthesiologist, not a nurse, not an administrator. You. So you keep going, just a bit longer.
And then, sometimes, miraculously, you win. It's all worth it. You've completely changed that person's life. You are the hero. You are the superstar.
But just as often, you have to quit. Your feet are too sore, the radiation dose too high, and the hour too late to safely continue. You have to face the family, the disappointed looks, the doubt about whether you were the right person to do this procedure, and the sad look on your patient's face when you break the news.
And you find yourself asking once again:
Why do I try so hard?
Why?
-Wes
Then you remember the story: the syncope, the wife, the kids, the vocation. They're depending on you. Not a tech, not an anesthesiologist, not a nurse, not an administrator. You. So you keep going, just a bit longer.
And then, sometimes, miraculously, you win. It's all worth it. You've completely changed that person's life. You are the hero. You are the superstar.
But just as often, you have to quit. Your feet are too sore, the radiation dose too high, and the hour too late to safely continue. You have to face the family, the disappointed looks, the doubt about whether you were the right person to do this procedure, and the sad look on your patient's face when you break the news.
And you find yourself asking once again:
Why do I try so hard?
Why?
-Wes
Friday, August 16, 2013
When Placing a Pacemaker, You Know You're on the Wrong Side When
... your wires look like this:
... and the venogram looks like this:
-Wes
 |
| AP fluoroscopic view |
... and the venogram looks like this:
 |
| Results of a left subclavian venogram |
-Wes
Wednesday, August 14, 2013
Heart Check Indeed: American Heart Association and Campbell Soup Company Sued
From Bloomberg:
Who's next? The Heart Truth® campaign, NHLBI, and the Coca Cola Company?
- Wes
Campbell Soup Company and the American Heart Association (AHA) were sued by a consumer who claimed the AHA fraudulently certifies the company’s products as healthy.Oh the irony, eh?
The association labels more than 30 of Campbell’s Healthy Request soups as “heart-healthy” even though a can has at least six times as much sodium as the organization recommends, according to a complaint filed yesterday by Kerry O’Shea in federal court in Camden, New Jersey. Those soups display the AHA’s “Heart-Check Mark” logo, which the organization licenses, according to the complaint.
Campbell, the world’s largest soup maker, and the heart association “falsely represent” that products with the logo have cardiovascular benefits lacking in other soups, according to the complaint.
Who's next? The Heart Truth® campaign, NHLBI, and the Coca Cola Company?
- Wes
Tuesday, August 13, 2013
EKG Du Jour 32: The Misfiring Pacemaker
A dual chamber pacemaker was implanted the prior day by a local surgeon in the operating room. The next morning, an EKG is obtained that showed the following:
You checked the CXR and all leads appeared to be in the proper location.
Does the patient have to go back to the operating room? Why or why not?
-Wes
 |
| Click to enlarge |
Does the patient have to go back to the operating room? Why or why not?
-Wes
Friday, August 09, 2013
Marketing Shared Patient Appointments
As health care reform kicks in to high gear, a new innovation in health care delivery is being touted at Cleveland Clinic: shared patient appointments. On the surface, this idea seems so efficient and social as patients with similar medical problems sit around in a group therapy session that masquerades as health care. After all, with the large influx of new patients to our health care system underway and the limited health care personnel resources available, the push for such a model was inevitable.
But many Americans are also noticing another disturbing trend: higher insurance premiums to offset the cost of those who do not have sufficient resources to pay for their care. While the reality of our higher health care costs demand that the added costs be paid by someone, I suspect most of those who will be paying higher premiums didn't think they'd have to "share" their physician appointments with others.
But here we are.
For large health care systems, shared patient appointments offer the promise of high revenue streams with low overhead costs. As such, there is no downside to promoting such a model:
-Wes
But many Americans are also noticing another disturbing trend: higher insurance premiums to offset the cost of those who do not have sufficient resources to pay for their care. While the reality of our higher health care costs demand that the added costs be paid by someone, I suspect most of those who will be paying higher premiums didn't think they'd have to "share" their physician appointments with others.
But here we are.
For large health care systems, shared patient appointments offer the promise of high revenue streams with low overhead costs. As such, there is no downside to promoting such a model:
Since 2005, the percentage of practices offering group visits has doubled, from 6% to 13% in 2010. With major provisions of the Affordable Care Act due to be implemented by next year, such group visits are also becoming attractive cost savers — patients who learn more about ways to prevent more serious disease can avoid expensive treatments. (ed's note: Sales pitch - there are no data that group appointments "prevent" more serious disease or "avoid" expensive treatments)Looking at this, how could anyone argue? It seems like such a helpful premise. But patients subjected to such a system have to agree one very important issue: surrendering their privacy:
“It’s a different way of speaking about health that is more about friends around a circle learning together than talking with an authority figure in a white coat,” says Dr. Jeff Cain, president of the American Academy of Family Physicians, in describing shared medical appointments. Think of them as a blend between group therapy and support groups. The net effect is the same – a sense of comfort, support and even motivation that comes from sharing similar experiences. (ed's note: Easy for him to say. Any proof?)
But they do require divulging and discussing private medical information in front of strangers (albeit ones who have signed waivers not to talk about other patients’ medical histories outside of the visit).
-Wes
Saturday, August 03, 2013
A Case of Fraud
He was a slender-framed man, mid- to late-sixties, with a kind of ridden-hard-put-away-wet complexion. It was clear the years had not always been good to him, but being the kind soul that he was, he had plenty of friends. It was a beautiful summer day to spend with friends for a barbecue, but he arrived feeling puzzled why he collapsed at home earlier in the day.
He stopped at the keg and poured himself a beer in a red solo cup, and as he approached his friends with a smile, he did it again, this time which such gusto that his beer went flying and the thud he made when he hit the ground made everyone gasp. He laid motionless for a moment face down on the ground while his friends rushed to his aid. An ambulance was summoned as others rolled him over onto his back. He began to move - slowly at first - then more purposefully. As sirens approached, he asked his friends, "What just happened?'
A bit later, he arrived in the Emergency Room, awake, alert, pleasant, and seemed - on the surface at least - fine. His vital signs were normal - perfect, in fact. About the only things immediately noticeable was his thin frame, his coffee-stained teeth, and a clump of grass in his hair that the nurse kindly removed. He was placed in the gurney, an IV was started, blood was drawn, and EKG was performed as a few "hellos" and "what happeneds" were exchanged, then off to the CT scanner he went to rule out an intracranial process. It was normal and his EKG showed a first-degree AV block and incomplete left bundle branch block without evidence of acute injury or prior heart attack.
He returned from the CT scanner and was examined a bit more closely. A loud, blowing, holosystolic murmur was heard by the medical student. In fact, it was loud enough to create a "thrill" - a palpable vibration on the thin man's chest. The medical student seemed pleased with himself, then ordered his first echo which revealed a relatively weak heart with a few chamber walls that didn't move so well, and a very leaky heart valve. He was admitted, placed on telemetry, and seen by a cardiology consultant. Closer inspection of the echo revealed a dilated left ventricle with a posterior wall motion defect and a central jet of mitral regurgitation large enough to fill the left atrium with a mosaic of color that extended to the pulmonary veins. It was clear he'd need surgery, so a diagnostic catheterization was performed. It showed three-vessel coronary artery disease and confirmed severe mitral regurgitation. His medications were adjusted and surgery consulted. A date for surgery was arranged at the neighboring hospital the following week and all seemed well.
But he had different plans.
As he settled down for dinner, he felt suddenly flushed, lightheaded, and broke out in a sweat. With that, the telemetry alarm sounded and soon the room was full of people, crash carts, and hysteria. His dinner table was shoved aside and he was laid flat as his chest was made bare. He didn't know what all the excitement was about, but heard the words "He's fibrillating!" and then felt the cool metal discs covered with cold goo applied to his chest. "What are you do...?" and with that, he felt his chest and arms jerk violently just before he passed out. "Shit, he's still fibrillating!" someone shouted. So they charged again and shocked him, this time to sinus rhythm. The anesthesiologists who had arrived on the scene of the arrest took no chances: he was intubated and expeditiously transferred to the ICU.
Upon arrival to the ICU, the patient was clearly recovering well and quickly extubated the next day. Beta blockers were administered additional anti-anginal and anticoagulants given. Once stabilized, he was transferred to the surgical hospital and underwent urgent bypass surgery with mitral valve replacement. At the time, the surgeon could see considerable endocardial scar.
His recovery was uncomplicated, but four days after his surgery, he still required external pacing. Cardiac electrophysiology was consulted to consider an ICD placement, given his history of sinus node dysfunction, cardiac arrest, diminished LV function, and the visible presence of endocardial scar during surgery.
The electrophysiologist reviewed the case and noted that the patient's original in-house arrhythmia at the time of his "arrest" was actually an organized, rapid ventricular tachycardia that was then shocked into ventricular fibrillation by an asynchronous defibrillation attempt. An echocardiogram performed post-operatively showed a very low EF of 23%, but a good repair of his valve and he appeared to be progressing quite nicely in his cardiac rehabilitation. Still, it was felt he was at high risk for another arrhythmic event, so a wearable defibrillator as ordered as they waited out his conduction system a bit longer to see if it would recover function. It never did.
So 10 days later after the sinus node failed to recover, the electrophysiologist had a choice: implant a pacemaker, or implant a defibrillator? It shouldn't be a difficult decision in this case, should it?
But the electrophysiologist knew he'd be committing fraud if he implanted a defibrillator and billed Medicare for the device and procedure. That's because Medicare's 2005 National Coverage Decision requires doctors to wait 90 days and then "reassessing" the patient's heart function later before implanting a defibrillator once the heart is revascularized surgically.
But he wondered about the extra risk of infection created by two surgeries (one for a pacemaker and one later to upgrade the device to an implantable defibrillator) instead of one. He wondered if anyone ever considered the frequent venous occlusions that preclude later upgrade of pacemakers to defibrillators via the same side as the original pacemaker implant. Even if he implanted a defibrillator lead at the same time he implanted the original pacemaker, wouldn't he be committing fraud if a more expensive defibrillator lead were billed to Medicare instead of a pacemaker lead? And what about the added cost, inconvenience, and poor compliance rates of patients issued wearable defibrillators as they wait out the 90-day waiting period for an ICD? Finally, what are the ethics of asking his patient to sign a form that obligates the patient to pay for his defibrillator if Medicare fails to do so when the actual costs involved to implant a defibrillator are closely held institutional secrets?
So he wrote his note. He documented his rationale thoroughly.
Then proceeded to commit fraud.
-Wes
Refs:
Fogel RI, et al. The Ultimate Dilemma: The Disconnect Between the Guidelines, the Appropriate Use Criteria, and Reimbursement Coverage Decisions JACC, 2013;() doi:10.1016/j.jacc.2013.07.016.
Dr. Wes: When the Feds Come Knocking
He stopped at the keg and poured himself a beer in a red solo cup, and as he approached his friends with a smile, he did it again, this time which such gusto that his beer went flying and the thud he made when he hit the ground made everyone gasp. He laid motionless for a moment face down on the ground while his friends rushed to his aid. An ambulance was summoned as others rolled him over onto his back. He began to move - slowly at first - then more purposefully. As sirens approached, he asked his friends, "What just happened?'
A bit later, he arrived in the Emergency Room, awake, alert, pleasant, and seemed - on the surface at least - fine. His vital signs were normal - perfect, in fact. About the only things immediately noticeable was his thin frame, his coffee-stained teeth, and a clump of grass in his hair that the nurse kindly removed. He was placed in the gurney, an IV was started, blood was drawn, and EKG was performed as a few "hellos" and "what happeneds" were exchanged, then off to the CT scanner he went to rule out an intracranial process. It was normal and his EKG showed a first-degree AV block and incomplete left bundle branch block without evidence of acute injury or prior heart attack.
He returned from the CT scanner and was examined a bit more closely. A loud, blowing, holosystolic murmur was heard by the medical student. In fact, it was loud enough to create a "thrill" - a palpable vibration on the thin man's chest. The medical student seemed pleased with himself, then ordered his first echo which revealed a relatively weak heart with a few chamber walls that didn't move so well, and a very leaky heart valve. He was admitted, placed on telemetry, and seen by a cardiology consultant. Closer inspection of the echo revealed a dilated left ventricle with a posterior wall motion defect and a central jet of mitral regurgitation large enough to fill the left atrium with a mosaic of color that extended to the pulmonary veins. It was clear he'd need surgery, so a diagnostic catheterization was performed. It showed three-vessel coronary artery disease and confirmed severe mitral regurgitation. His medications were adjusted and surgery consulted. A date for surgery was arranged at the neighboring hospital the following week and all seemed well.
But he had different plans.
As he settled down for dinner, he felt suddenly flushed, lightheaded, and broke out in a sweat. With that, the telemetry alarm sounded and soon the room was full of people, crash carts, and hysteria. His dinner table was shoved aside and he was laid flat as his chest was made bare. He didn't know what all the excitement was about, but heard the words "He's fibrillating!" and then felt the cool metal discs covered with cold goo applied to his chest. "What are you do...?" and with that, he felt his chest and arms jerk violently just before he passed out. "Shit, he's still fibrillating!" someone shouted. So they charged again and shocked him, this time to sinus rhythm. The anesthesiologists who had arrived on the scene of the arrest took no chances: he was intubated and expeditiously transferred to the ICU.
Upon arrival to the ICU, the patient was clearly recovering well and quickly extubated the next day. Beta blockers were administered additional anti-anginal and anticoagulants given. Once stabilized, he was transferred to the surgical hospital and underwent urgent bypass surgery with mitral valve replacement. At the time, the surgeon could see considerable endocardial scar.
His recovery was uncomplicated, but four days after his surgery, he still required external pacing. Cardiac electrophysiology was consulted to consider an ICD placement, given his history of sinus node dysfunction, cardiac arrest, diminished LV function, and the visible presence of endocardial scar during surgery.
The electrophysiologist reviewed the case and noted that the patient's original in-house arrhythmia at the time of his "arrest" was actually an organized, rapid ventricular tachycardia that was then shocked into ventricular fibrillation by an asynchronous defibrillation attempt. An echocardiogram performed post-operatively showed a very low EF of 23%, but a good repair of his valve and he appeared to be progressing quite nicely in his cardiac rehabilitation. Still, it was felt he was at high risk for another arrhythmic event, so a wearable defibrillator as ordered as they waited out his conduction system a bit longer to see if it would recover function. It never did.
So 10 days later after the sinus node failed to recover, the electrophysiologist had a choice: implant a pacemaker, or implant a defibrillator? It shouldn't be a difficult decision in this case, should it?
But the electrophysiologist knew he'd be committing fraud if he implanted a defibrillator and billed Medicare for the device and procedure. That's because Medicare's 2005 National Coverage Decision requires doctors to wait 90 days and then "reassessing" the patient's heart function later before implanting a defibrillator once the heart is revascularized surgically.
But he wondered about the extra risk of infection created by two surgeries (one for a pacemaker and one later to upgrade the device to an implantable defibrillator) instead of one. He wondered if anyone ever considered the frequent venous occlusions that preclude later upgrade of pacemakers to defibrillators via the same side as the original pacemaker implant. Even if he implanted a defibrillator lead at the same time he implanted the original pacemaker, wouldn't he be committing fraud if a more expensive defibrillator lead were billed to Medicare instead of a pacemaker lead? And what about the added cost, inconvenience, and poor compliance rates of patients issued wearable defibrillators as they wait out the 90-day waiting period for an ICD? Finally, what are the ethics of asking his patient to sign a form that obligates the patient to pay for his defibrillator if Medicare fails to do so when the actual costs involved to implant a defibrillator are closely held institutional secrets?
So he wrote his note. He documented his rationale thoroughly.
Then proceeded to commit fraud.
-Wes
Refs:
Fogel RI, et al. The Ultimate Dilemma: The Disconnect Between the Guidelines, the Appropriate Use Criteria, and Reimbursement Coverage Decisions JACC, 2013;() doi:10.1016/j.jacc.2013.07.016.
Dr. Wes: When the Feds Come Knocking
Friday, August 02, 2013
Images of Change: The Patient Appointment
 |
| Time Discarded |
Submitted as part of Image of Change: A Health Care Evolution Photo Contest. Feel free to submit yours (Instructions at the link). -Wes
Thursday, August 01, 2013
Images of Change: Clicking is Caring
Submitted as part of Image of Change: A Health Care Evolution Photo Contest. Feel free to submit yours (Instructions at the link). -Wes
 |
| “The secret of the care of the patient is in caring for the patient.” - F. Peabody |
Submitted as part of Image of Change: A Health Care Evolution Photo Contest. Feel free to submit yours (Instructions at the link). -Wes
Images of Change: Going Private
 |
| The Loss of Roommates, courtesy D. Graf |
Submitted as part of Image of Change: A Health Care Evolution Photo Contest. Feel free to submit yours (Instructions at the link). -Wes
Wednesday, July 31, 2013
Images of Change: Charting
 |
| Image courtesy Kathy Neider, MD, Staff Physician, Baptist Health |
"I'm sitting where my credenza used to be, stacked high with charts. I figured if I was going to be in my office till late at night finishing electronic charting, it might as well be in a comfortable place."
Submitted as part of Image of Change: A Health Care Evolution Photo Contest. Feel free to submit yours (Instructions at the link). -Wes
Friday, July 26, 2013
An Open Letter to Patient's With Pre-excited Afib and Ischemic VT
Dear Mr. or Ms. Patient With Pre-excited Afib or Ischemic VT:
I just wanted to let you know, if you come to our ER, you are screwed. Currently, our best drug to deal with your arrhythmias of pre-excited atrial fibrillation (afib) or ischemic ventricular tachycardia is not available anywhere: procainamide. It seems the one drug company who makes this drug (Hospira) has a few manufacturing delays (oops), so the drug is on backorder.
So come ready to have your heart shocked.
Hopefully we'll have some analgesic or anesthetic drugs available in our pharmacy that aren't on backorder so you won't feel your cardioversion.
Wishing you the best, as always...
-Wes
I just wanted to let you know, if you come to our ER, you are screwed. Currently, our best drug to deal with your arrhythmias of pre-excited atrial fibrillation (afib) or ischemic ventricular tachycardia is not available anywhere: procainamide. It seems the one drug company who makes this drug (Hospira) has a few manufacturing delays (oops), so the drug is on backorder.
So come ready to have your heart shocked.
Hopefully we'll have some analgesic or anesthetic drugs available in our pharmacy that aren't on backorder so you won't feel your cardioversion.
Wishing you the best, as always...
-Wes
Thursday, July 25, 2013
Images of Change: A Health Care Evolution Photo Contest
Much of my interest in writing about health care has been the changes I've noticed and experienced over the years of practicing medicine: some good, some not-so-good. Pictures of these changes to health care, I've found, are limited. Sooo, I thought it would be fun to create a contest of sorts: perhaps it will be well-recieved, perhaps not, I have no idea. But the idea is this: try to capture an aspect of change in health care that you've noticed in a single photograph.
Almost all of us carry a smart phone. As such, we have a perfect opportunity to capture images that might embody some change we have seen in health care. Send it to me at wes - at - medtees dot com, tell me why you think this represents "change," and I'll add them to this blog from time to time if there's enough interest. Be careful not to include any patient images, please (HIPAA frowns on that), and keep the content professional. Send as many as you want, but please don't send super-high res images or my mailbox will become overloaded quickly. (I am celebrating that my blog finally has more than two readers a day!) After I collect as many as I can over the next several months, I'll post all of those I've received in a photoshopped collage, then let people pick the image they feel best depicts health care's most significant "change." So tell friends at the New York Times, the Wall Street Journal, retweet the post, put this exceptional contest on Facebook, Pinterest, and LinkedIn - the more the merrier. Then have fun.
What will you receive for your efforts? Once selected, the grand prize winner will receive worldwide recognition as the "The Biggest Change Agent, 2013!" (Sorry, monetary prizes are easily gamed and might miss the spirit of the contest - yes, Virginia, this is strictly for fun and entertainment.) (If someone want's to help contribute some real coin to the effort, e-mail me and maybe we can make a real prize contest out of this...)
So be thinking about this (in all of your spare time), snap a pic, and send it on. I'd love to see what others are seeing around the country (or around the world) as health care changes faster than ever.
To get you started: here's a picture I took today. I think it speaks volumes:
-Wes
Almost all of us carry a smart phone. As such, we have a perfect opportunity to capture images that might embody some change we have seen in health care. Send it to me at wes - at - medtees dot com, tell me why you think this represents "change," and I'll add them to this blog from time to time if there's enough interest. Be careful not to include any patient images, please (HIPAA frowns on that), and keep the content professional. Send as many as you want, but please don't send super-high res images or my mailbox will become overloaded quickly. (I am celebrating that my blog finally has more than two readers a day!) After I collect as many as I can over the next several months, I'll post all of those I've received in a photoshopped collage, then let people pick the image they feel best depicts health care's most significant "change." So tell friends at the New York Times, the Wall Street Journal, retweet the post, put this exceptional contest on Facebook, Pinterest, and LinkedIn - the more the merrier. Then have fun.
What will you receive for your efforts? Once selected, the grand prize winner will receive worldwide recognition as the "The Biggest Change Agent, 2013!" (Sorry, monetary prizes are easily gamed and might miss the spirit of the contest - yes, Virginia, this is strictly for fun and entertainment.) (If someone want's to help contribute some real coin to the effort, e-mail me and maybe we can make a real prize contest out of this...)
So be thinking about this (in all of your spare time), snap a pic, and send it on. I'd love to see what others are seeing around the country (or around the world) as health care changes faster than ever.
To get you started: here's a picture I took today. I think it speaks volumes:
 |
| Mailboxes in the Physician Lounge (Click to enlarge) |
Wednesday, July 24, 2013
When Your 26-year Old Needs Insurance
My son was born in 1987. Like many kids his age, he is currently "underemployed" as he struggles to get an internet start-up idea off the ground. Thanks to our new health care law, he was able to stay on my insurance until he reached the magic age of 26. But the honeymoon has ended and recently I began the process of deciding if I should continue him on my Cobra plan at the high price of $485.14 per month or seek a high-deductible major medical plan instead.
Being former military, I have homeowners and car insurance through USAA. So I was interested when they sent me a marketing e-mail suggesting I might want to look at health insurance options available for my son. The plans were offered by "Assurant Health Care," so I thought I'd explore what this one company offered.
First, Assurant Health offered three options for coverage: (1) Fixed-benefit Insurance starting at $67 per month, (2) Temporary Insurance starting at $86.74 per month, and (3) Major Medical Insurance starting at $90.74 per month. So far so good.
Fixed-benefit insurance, I learned, is different from major medical insurance since it pays set cash amounts (fixed benefits) when a person receives medical services. Depending on what providers charge, my son might (scratch that, probably will) have to pay a portion of his health care bill and cap at a $1 million, $2 million, or $3 million lifetime benefit, depending on much he'd like to pay each month.
Temporary insurance is marketed as "30 to 180 days of short term insurance coverage. Protection is provided when you're between jobs, waiting for employer benefits, or in temporary, seasonal or contract work." Hmm, this seemed like a possibility provided he can get a job in that period of time. Oh wait, this hasn't gone so well so far, so this might not be the best option for him.
Major Medical insurance: was being marketed as insurance similar to what I have now, except with a varying sized deductibles and no life-time care limit.
On the surface, each of these options looked possible until I read the fine print on all of them: pre-existing conditions would not be covered by any of the above plans. But my son has a few pre-existing conditions. Wait, doesn't our new health care law cover people with pre-existing conditions?
As I recall, the Pre-existing Condition Insurance Plan (PCIP) is overseen by the Center for Consumer Information and Insurance Oversight (CCIIO) created through our new health care plan and under the auspices of the Department of Health and Human Services. To be eligible for the PCIP, “individuals must have a pre-existing condition and have been without creditable coverage for at least 6 months prior to application,” explained the Governement Account Office that limits “the program to individuals who likely have been unable to access insurance because of their pre-existing condition.”
Now he just lost his insurance, right? So he has to wait 6 months? Can you say "Catch-22?"
To make matters much worse, the PCIP ran out of money in February, 2013 so the Department of Health and Human Services stopped enrolling patients with pre-existing conditions who might need coverage. What does this mean for the rest of our new health care law's ability to pay for U.S. citizens as insurers offload all their patients with pre-existing conditions on them? Will Congress assure there be enough money available to care for patients with pre-existing conditions when the new health care law goes into effect? And why hasn't this been fixed by now? This should sound a prescient warning concerning correcting problems with the law to us all.
His only other option currently is to enroll in Illinois CountyCare, a Medicaid program constructed on the back of the Affordable Care Act. It provides limited services and not all doctors are part of CountyCare, I learned. In fact, according to their website:
"Only doctors that are part of the CountyCare network may accept CountyCare patients. When an individual enrolls in CountyCare, they will be asked to select a patient centered medical home site from a list of participating providers. Choices will include Cook County Health & Hospital System sites as well as some other community providers, such as community health centers."
But at least he'd have some health care, right?
It is hard to say. He might have insurance, but access to providers might be very difficult, especially when we consider Cook County, the second most populous county in America, has 40.5% of the entire population of Illinois within its border.
Given these options, it appears my son will likely continue his Cobra plan for now, since the devil you know is better than the devil you don't know.
Now I consider myself fairly medically savvy. I read fine print. I am fortunate to have financial resources. And I like the ability to choose between options for my son's insurance needs. But it looks like the depth and breadth of health care options for young adults without pre-existing conditions is going to be staggering but with many coverage loopholes. For those young adults with pre-existing conditions, their options for care will remain quite limited, especially if they're unemployed or underemployed.
I feel for the young, under-employed who are less medically-saavy and have no fallback options for care. Will they obtain the wrong insurance or be underinsured as they fumble through a variety of websites that offer hundreds of coverage options? Will they have to find a new doctor beginning in 2014?
It seems so.
Welcome to the insurance nightmare of the Obamacare Underworld.
-Wes
Being former military, I have homeowners and car insurance through USAA. So I was interested when they sent me a marketing e-mail suggesting I might want to look at health insurance options available for my son. The plans were offered by "Assurant Health Care," so I thought I'd explore what this one company offered.
First, Assurant Health offered three options for coverage: (1) Fixed-benefit Insurance starting at $67 per month, (2) Temporary Insurance starting at $86.74 per month, and (3) Major Medical Insurance starting at $90.74 per month. So far so good.
Fixed-benefit insurance, I learned, is different from major medical insurance since it pays set cash amounts (fixed benefits) when a person receives medical services. Depending on what providers charge, my son might (scratch that, probably will) have to pay a portion of his health care bill and cap at a $1 million, $2 million, or $3 million lifetime benefit, depending on much he'd like to pay each month.
Temporary insurance is marketed as "30 to 180 days of short term insurance coverage. Protection is provided when you're between jobs, waiting for employer benefits, or in temporary, seasonal or contract work." Hmm, this seemed like a possibility provided he can get a job in that period of time. Oh wait, this hasn't gone so well so far, so this might not be the best option for him.
Major Medical insurance: was being marketed as insurance similar to what I have now, except with a varying sized deductibles and no life-time care limit.
On the surface, each of these options looked possible until I read the fine print on all of them: pre-existing conditions would not be covered by any of the above plans. But my son has a few pre-existing conditions. Wait, doesn't our new health care law cover people with pre-existing conditions?
As I recall, the Pre-existing Condition Insurance Plan (PCIP) is overseen by the Center for Consumer Information and Insurance Oversight (CCIIO) created through our new health care plan and under the auspices of the Department of Health and Human Services. To be eligible for the PCIP, “individuals must have a pre-existing condition and have been without creditable coverage for at least 6 months prior to application,” explained the Governement Account Office that limits “the program to individuals who likely have been unable to access insurance because of their pre-existing condition.”
Now he just lost his insurance, right? So he has to wait 6 months? Can you say "Catch-22?"
To make matters much worse, the PCIP ran out of money in February, 2013 so the Department of Health and Human Services stopped enrolling patients with pre-existing conditions who might need coverage. What does this mean for the rest of our new health care law's ability to pay for U.S. citizens as insurers offload all their patients with pre-existing conditions on them? Will Congress assure there be enough money available to care for patients with pre-existing conditions when the new health care law goes into effect? And why hasn't this been fixed by now? This should sound a prescient warning concerning correcting problems with the law to us all.
His only other option currently is to enroll in Illinois CountyCare, a Medicaid program constructed on the back of the Affordable Care Act. It provides limited services and not all doctors are part of CountyCare, I learned. In fact, according to their website:
"Only doctors that are part of the CountyCare network may accept CountyCare patients. When an individual enrolls in CountyCare, they will be asked to select a patient centered medical home site from a list of participating providers. Choices will include Cook County Health & Hospital System sites as well as some other community providers, such as community health centers."
But at least he'd have some health care, right?
It is hard to say. He might have insurance, but access to providers might be very difficult, especially when we consider Cook County, the second most populous county in America, has 40.5% of the entire population of Illinois within its border.
Given these options, it appears my son will likely continue his Cobra plan for now, since the devil you know is better than the devil you don't know.
Now I consider myself fairly medically savvy. I read fine print. I am fortunate to have financial resources. And I like the ability to choose between options for my son's insurance needs. But it looks like the depth and breadth of health care options for young adults without pre-existing conditions is going to be staggering but with many coverage loopholes. For those young adults with pre-existing conditions, their options for care will remain quite limited, especially if they're unemployed or underemployed.
I feel for the young, under-employed who are less medically-saavy and have no fallback options for care. Will they obtain the wrong insurance or be underinsured as they fumble through a variety of websites that offer hundreds of coverage options? Will they have to find a new doctor beginning in 2014?
It seems so.
Welcome to the insurance nightmare of the Obamacare Underworld.
-Wes
administration’s Health and Human Services Department (HHS) has stopped enrolling any new people in the program, according to an audit by the General Accountability Office (GAO). - See more at: http://cnsnews.com/news/article/gao-hhs-already-rationing-enrollment-obamacare-s-pre-existing-condition-plan#sthash.EZVgmKIe.dpuf
administration’s Health and Human Services Department (HHS) has stopped enrolling any new people in the program, according to an audit by the General Accountability Office (GAO). - See more at: http://cnsnews.com/news/article/gao-hhs-already-rationing-enrollment-obamacare-s-pre-existing-condition-plan#sthash.EZVgmKIe.dpuf
Friday, July 19, 2013
Paying It Foward
Finally, a warm, sunny day in the city of Chicago after an unusually cool, rainy Spring. The fireworks the night before were watched through a low layer of clouds on a dreadfully still summer night, but the threatening rains never came. Today, though, had been sunnier, brigher, and a wonderful day to enjoy the beach. The July 4th crowd was large but manageable, and most were returning home to get ready for the evening's activities.
Philip noticed the other gentleman not much older than himself as he was returning his Catamaran to it's rightful spot on the beach. The other man had just returned his kayak to its slip and was loading his car with beach supplies. As he finished loading the car, he slammed the back hatch door of the car, turned to walk away, but suddenly collapsed to the ground in a heap.
He didn't move.
Seeing the strange sight, Philip ran to his aid. The fallen man was lying there with eyes staring skyward, not blinking. His lips and ears were turning bluish as the tall man shouted at him. He didn't respond. Philip checked for a pulse: nothing. Others were circling, curious as he positioned the man face up on the nearby asphalt. The onlookers looked confused, amazed at what they were witnessing. He began pressing on the lower part of the man's chest. Again, again, and again.
He looked up and shouted as calmly as he could, "Call 911." The bystanders, still dazed, reached for their cell phones as fast as they could and dialed. By now the attendants at the sailing shack had noticed what had happened and had radioed for help, too. The AED and oxygen were at the swim beach, about a quarter of a mile away. A young 16-year old lifeguard, his first day on the job, ran to the scene and reached in to his fanny pack to remove the facemask and worked with the tall, fit man doing CPR.
"Hang in there, Bill! (not his real name)," the onlookers shouted. "Don't leave us!" he remembered them saying as they stood by in tears hugging each other. He kept doing CPR. "They're coming with the AED!" someone shouted.
He could hear the sirens approaching ...
* * *
Twenty five years earlier, he was home with his mother in the kitchen when the girl arrived in their kitchen, bloodied, and wearing a large blue garbage bag as shorts. "Help me," she pleaded, "I was raped, but I managed to shoot him," she claimed. The bloodied shorts and two guns she held in her hands seemed to substantiate her claim. She was trembling, aggitated and seemed terrified. "The police are going to find me and think that I'm a murderer!"
"It's okay," the mother said, trying to calm her. "Sit down. What's your name?"
"Laurie," she said. "Laurie Dann."
"It's okay, Laurie. You're going to be okay," she said as she tried to console her. "I can get you some shorts. The police will understand that you were just trying to protect yourself." The girl still looked too upset, untrusting. The son stood watching carefully as the mother left only briefly and returned with a pair of girl's shorts. "Here, put these on."
The girl put down the two handguns and went behind the counter briefly to to put on the shorts. Phil, not turning his back to the girl, quietly managed to pick up and pocket one of the guns. "Maybe you should call your family?" he asked. She shook her head in agreement and he handed her the phone.
She took the phone and dialed, still holding the remaining gun. "Mom, oh my God, I've... I've done something horrible! He tried to ... The police are going to get me, Mom! Oh, God!..." She broke into tears unable to maintain her composure. She handed Phil the phone.
"Ma'am, my name is Philip Andrew and your daughter is here with us. She is fine, but looks very upset. She tells us she's been raped and might have shot the man who raped her. I think you should come over..." The mother said she'd try to get there as soon as she could, but she didn't have a car. Phil felt uneasy with the situation, but the girl looked confused. They tried to console her.
A short time later, the father arrived home. He saw the girl with his wife and son sitting there, trying to coax Laurie into giving up her gun. She wouldn't budge. She rocked too and fro describing the scene, her terror, her anxiety. The family kept trying to console her, explain the rationale for giving up the gun. Deflecting, they asked, "Maybe you should call your mother again." They handed her the phone. She called.
This time, the mother managed to leave the house as Laurie spoke with her own mother. Her words were disjointed in some respects, calculating in others. After pleading with her mother to come, Laurie handed the husband the phone so he could speak with Laurie's mother. He told her about the gun Laurie still had and asked the mother if she might plead with her daughter to give up the gun. He handed the phone back to Laurie and told her he would not remain in the house to protect her from the police unless she put down the gun. She still refused, so the man left the house. As Phil tried to leave, she ordered him to stay. She pointed the gun at him. He stood motionless, terrifed.
The standoff continued until just before noon and she became increasingly aggitated. As Laurie saw the police approach, she shot Phil in the chest and gave chase, furious at the situation, but he managed to escape out the back door before collapsing. She ran upstairs.
As he laid there, he could hear the sirens approaching...
* * *
They slapped the AED pads on his chest and stopped compressions. "Analyzing..." the screen said. The device detected ventricular fibrillation and shortly after the device said "Stand clear!" the man jerked. They resumed CPR for a short time, but in 30 seconds the man started moving. The sirens were almost upon them now.
As the ambulance crew arrived, they couldn't believe their eyes. The man who moments ago had had chest compressions administered and an AED shock delivered, was getting to his feet. They helped him to the ambulance.
"This impressed my crew, my guys, so much …" Wilmette Deputy Fire Chief Mike McGreal said a the recent Wilmette park board meeting honoring the beach staff.
But to Philip Andrew, now a crisis negotiator for the FBI who was on the beach with his wife that day, he'll never forget the sound of the sirens...
... and the emergency responders that saved his life twenty five years before.
"There's something really beautiful about being able to pay it forward," he said.
-Wes
References:
"Wilmette lifeguards honored after July 4 rescue"
Laurie Dann Wikipedia page
Philip noticed the other gentleman not much older than himself as he was returning his Catamaran to it's rightful spot on the beach. The other man had just returned his kayak to its slip and was loading his car with beach supplies. As he finished loading the car, he slammed the back hatch door of the car, turned to walk away, but suddenly collapsed to the ground in a heap.
He didn't move.
Seeing the strange sight, Philip ran to his aid. The fallen man was lying there with eyes staring skyward, not blinking. His lips and ears were turning bluish as the tall man shouted at him. He didn't respond. Philip checked for a pulse: nothing. Others were circling, curious as he positioned the man face up on the nearby asphalt. The onlookers looked confused, amazed at what they were witnessing. He began pressing on the lower part of the man's chest. Again, again, and again.
He looked up and shouted as calmly as he could, "Call 911." The bystanders, still dazed, reached for their cell phones as fast as they could and dialed. By now the attendants at the sailing shack had noticed what had happened and had radioed for help, too. The AED and oxygen were at the swim beach, about a quarter of a mile away. A young 16-year old lifeguard, his first day on the job, ran to the scene and reached in to his fanny pack to remove the facemask and worked with the tall, fit man doing CPR.
"Hang in there, Bill! (not his real name)," the onlookers shouted. "Don't leave us!" he remembered them saying as they stood by in tears hugging each other. He kept doing CPR. "They're coming with the AED!" someone shouted.
He could hear the sirens approaching ...
* * *
Twenty five years earlier, he was home with his mother in the kitchen when the girl arrived in their kitchen, bloodied, and wearing a large blue garbage bag as shorts. "Help me," she pleaded, "I was raped, but I managed to shoot him," she claimed. The bloodied shorts and two guns she held in her hands seemed to substantiate her claim. She was trembling, aggitated and seemed terrified. "The police are going to find me and think that I'm a murderer!"
"It's okay," the mother said, trying to calm her. "Sit down. What's your name?"
"Laurie," she said. "Laurie Dann."
"It's okay, Laurie. You're going to be okay," she said as she tried to console her. "I can get you some shorts. The police will understand that you were just trying to protect yourself." The girl still looked too upset, untrusting. The son stood watching carefully as the mother left only briefly and returned with a pair of girl's shorts. "Here, put these on."
The girl put down the two handguns and went behind the counter briefly to to put on the shorts. Phil, not turning his back to the girl, quietly managed to pick up and pocket one of the guns. "Maybe you should call your family?" he asked. She shook her head in agreement and he handed her the phone.
She took the phone and dialed, still holding the remaining gun. "Mom, oh my God, I've... I've done something horrible! He tried to ... The police are going to get me, Mom! Oh, God!..." She broke into tears unable to maintain her composure. She handed Phil the phone.
"Ma'am, my name is Philip Andrew and your daughter is here with us. She is fine, but looks very upset. She tells us she's been raped and might have shot the man who raped her. I think you should come over..." The mother said she'd try to get there as soon as she could, but she didn't have a car. Phil felt uneasy with the situation, but the girl looked confused. They tried to console her.
A short time later, the father arrived home. He saw the girl with his wife and son sitting there, trying to coax Laurie into giving up her gun. She wouldn't budge. She rocked too and fro describing the scene, her terror, her anxiety. The family kept trying to console her, explain the rationale for giving up the gun. Deflecting, they asked, "Maybe you should call your mother again." They handed her the phone. She called.
This time, the mother managed to leave the house as Laurie spoke with her own mother. Her words were disjointed in some respects, calculating in others. After pleading with her mother to come, Laurie handed the husband the phone so he could speak with Laurie's mother. He told her about the gun Laurie still had and asked the mother if she might plead with her daughter to give up the gun. He handed the phone back to Laurie and told her he would not remain in the house to protect her from the police unless she put down the gun. She still refused, so the man left the house. As Phil tried to leave, she ordered him to stay. She pointed the gun at him. He stood motionless, terrifed.
The standoff continued until just before noon and she became increasingly aggitated. As Laurie saw the police approach, she shot Phil in the chest and gave chase, furious at the situation, but he managed to escape out the back door before collapsing. She ran upstairs.
As he laid there, he could hear the sirens approaching...
* * *
They slapped the AED pads on his chest and stopped compressions. "Analyzing..." the screen said. The device detected ventricular fibrillation and shortly after the device said "Stand clear!" the man jerked. They resumed CPR for a short time, but in 30 seconds the man started moving. The sirens were almost upon them now.
As the ambulance crew arrived, they couldn't believe their eyes. The man who moments ago had had chest compressions administered and an AED shock delivered, was getting to his feet. They helped him to the ambulance.
"This impressed my crew, my guys, so much …" Wilmette Deputy Fire Chief Mike McGreal said a the recent Wilmette park board meeting honoring the beach staff.
But to Philip Andrew, now a crisis negotiator for the FBI who was on the beach with his wife that day, he'll never forget the sound of the sirens...
... and the emergency responders that saved his life twenty five years before.
"There's something really beautiful about being able to pay it forward," he said.
-Wes
References:
"Wilmette lifeguards honored after July 4 rescue"
Laurie Dann Wikipedia page
The Silent Majority
There is so much entropy in health care right now. So much finagling, so much shifting, so much arguing, so much uncertainty, so much shock. Shock at prices, shock at waiting times, shock that doctors don't know how to increase referrals, shock that doctors aren't doing more to help. What gives?
In triage, you don't spend time with the expectant.
Doctors are keeping their heads down. They are still seeing patients. They are still going to work and taking the calls.
But they are tired. They are frustrated by the system that puts the system of care before the people doing the caring and those needing care. They are tired of the empty promises. Like the promises that staring at a keyboard will fix things, do things better, save money. It's complicated, this health care thing, right? We are told we need more automation. We need more quality managers. We need more safety officers to see more people with less to keep it safe. We need more administrators to implement the rules: more people willing to take less to make it work. Complicated, I tell you.
But the promises, we're learning, have been part empty, for they have enriched the system for the system's sake while leaving the people the system is supposed to help, increasingly broke. We're $500 billion over budget so far and counting.
Promises are for politicians and business people. Real health care workers don't make promises, they do the best they can with what God gave us. As patch after destructive patch of interweaving laws and back-slapping favors are handed out in Washington, corporate board rooms, and union meeting halls, a silent health care majority watches from their peripheral vision, trying not to notice, trying not to be disgusted, for the work for them never ends. The silent majority is waking to the fact that the business part of health care was, is, and somehow forever shall be, broken. There is simply too much money involved, too much economic return that can still be made, too many opportunities to deceive others for personal gain, too many people, too many workers, too much of our economy, to accept that things will ever really change. Too very, very big...
... to fail.
Like Detroit.
I sit before a computer screen that says "Order entry:" I no longer need a pen thanks to handsome government subsidies and a push to centralize and nationalize. Let others do the deciding.
I type in an order.
Five choices instantly appear based an a sophisticated word-search algorithm. I find what my patient and I, as their caregiver, need. I click on the item.
But a price never shown. So there is never a discussion about cost. That's the intent. There is never a word about the difference of retail price and what it really costs or what you'll really have to pay. Like a shopping spree without the prices. Because, according to others, doctors should not think of these things when health care is involved, nor should Congress - it's about your health, remember?
So thousands and thousands of your dollars are put at risk, dear patient, with a single click of a button. Courtesy of government subsidies. And you will never know. Nor will I, as I load the gun of your economic destruction.
So efficient. So clean. So tidy.
How was I supposed to know I ordered a collection agency for you, too?
But the silent majority is stirring. They are upset they must pay their mandate, upset the corporate guys don't. The are seeing the bills, the denials, and the undecipherable bills. They are seeing the cost.
The Silent Majority is stirring.
Because they have a check box, too.
In November, 2014.
-Wes
In triage, you don't spend time with the expectant.
Doctors are keeping their heads down. They are still seeing patients. They are still going to work and taking the calls.
But they are tired. They are frustrated by the system that puts the system of care before the people doing the caring and those needing care. They are tired of the empty promises. Like the promises that staring at a keyboard will fix things, do things better, save money. It's complicated, this health care thing, right? We are told we need more automation. We need more quality managers. We need more safety officers to see more people with less to keep it safe. We need more administrators to implement the rules: more people willing to take less to make it work. Complicated, I tell you.
But the promises, we're learning, have been part empty, for they have enriched the system for the system's sake while leaving the people the system is supposed to help, increasingly broke. We're $500 billion over budget so far and counting.
Promises are for politicians and business people. Real health care workers don't make promises, they do the best they can with what God gave us. As patch after destructive patch of interweaving laws and back-slapping favors are handed out in Washington, corporate board rooms, and union meeting halls, a silent health care majority watches from their peripheral vision, trying not to notice, trying not to be disgusted, for the work for them never ends. The silent majority is waking to the fact that the business part of health care was, is, and somehow forever shall be, broken. There is simply too much money involved, too much economic return that can still be made, too many opportunities to deceive others for personal gain, too many people, too many workers, too much of our economy, to accept that things will ever really change. Too very, very big...
... to fail.
Like Detroit.
I sit before a computer screen that says "Order entry:" I no longer need a pen thanks to handsome government subsidies and a push to centralize and nationalize. Let others do the deciding.
I type in an order.
Five choices instantly appear based an a sophisticated word-search algorithm. I find what my patient and I, as their caregiver, need. I click on the item.
But a price never shown. So there is never a discussion about cost. That's the intent. There is never a word about the difference of retail price and what it really costs or what you'll really have to pay. Like a shopping spree without the prices. Because, according to others, doctors should not think of these things when health care is involved, nor should Congress - it's about your health, remember?
So thousands and thousands of your dollars are put at risk, dear patient, with a single click of a button. Courtesy of government subsidies. And you will never know. Nor will I, as I load the gun of your economic destruction.
So efficient. So clean. So tidy.
How was I supposed to know I ordered a collection agency for you, too?
But the silent majority is stirring. They are upset they must pay their mandate, upset the corporate guys don't. The are seeing the bills, the denials, and the undecipherable bills. They are seeing the cost.
The Silent Majority is stirring.
Because they have a check box, too.
In November, 2014.
-Wes
Tuesday, July 16, 2013
Spousal Travel Fees and the Cost of Medical Board Certification
Recently, I have been enduring my "Maintenance Of Certification" (MOC) training so I can continue to call myself "Board Certified" in Cardiovascular Diseases and Cardiac Electrophysiology. Later this year, I will sit for my re-certification examinations. But I was also recently reminded just how expensive this process has become for doctors.
Yesterday, I received a $775 bill for my "additional examination fee" from the American Board of Internal Medicine (ABIM) in the mail. I was surprised and had to ask myself, "Why?" Especially since this rate is more expensive than staying at a five-star hotel room in Chicago for a day.
In total, the out-of-pocket expenses for Maintenance of Certification in both of my subspecialties above have been as follows:
But when we learn of the salaries of the leadership of the ABIM, it becomes clear why these fees are so high. According to the publically-available IRS Form 990 from 2012 (the last available), ABIM Executive Christine K Cassel received salary and benefits of $786,751 in 2011, plus payments for spousal travel. (At that salary, why are testing physicians picking up travel expenses for Dr. Cassel's husband?)
Equally outrageous has been the ABIM's recent requirement for re-certifying physicians to complete a "Practice Improvement Module" as part of their re-certification requirements. For those unfamiliar, doctors have to find something to improve in their practice, measure how its going, make a change, then measure the effect of that strategy in hopes it will improve patient care. On the surface this requirement seems so, well, nifty! How could anyone argue with the intent of such a requirement? But imagine the time it takes to conceive and execute such a project. How much patient care suffers as a result? So doctors who are already stretched for time look for ways around this requirement and luckily, they find it is easily gamed. So they talk to their hospital's quality coordinator, get some useful data, enter it into the MOC website, then answer questions that ask "what-did-you-learn-as-a-result-of-completing-this-module?" and, presto! Their module is done!
Really, is this useful? Maybe we should include handwashing exercises, too. Or is this more about the ABIM maintaining their leadership's benefits and political favor? As I performed this painful part of my re-certification requirement, I couldn't help but hear echo's of Don Berwick's Institute for Healthcare Improvement's educational curriculum that helped pave the way for the life-long healthcare guartantee he received for himself and his family for life. Could the leadership of the ABIM have similar aspirations for a similar golden parachute?
I can't help but wonder.
As I wrote my additional exam fee check, I also reflected on what the "value" of this re-certification process is for physicians like myself that have been previously certified.
Will doctors get more income for having this certification? No, especially in the current payer climate that seeks to continue to limit physician payments.
Will doctors get more prestige for having this certification? Not really, especially when nurse practitioners at Walgreens can call themselves "board certified," too. (It is interesting to note that their certification only costs $395 - 8.4% of the cost for medical re-certification. Maybe doctors should take their test instead?) What responsibility does the ABIM have to protect the value of the term "board certification" for physicians who invest in this process? Given the ongoing board "certificate" fraud perpetuated by others directly under the nose of the ABIM, we are left to wonder if they have any authority to protect physicians' investment in this process.
Is the time required to re-certify worth it for doctors and patients? Will doctors be smarter for having this certification? I think the ABIM does try to make the knowledge assessment modules relevant to new knowledge in the medical field. (Actually, I found these almost fun to take). But I already stay up to date with current innovations and studies in my field thanks to my teaching responsibilities, ongoing state licensure requirements for continuing medical education credits, and my rather healthy social media presence. Do these costly re-certification tests improve my knowledge significantly enough to affect my patient's outcomes? I honestly don't think I've ever felt so.
Surely the public wants to know their doctors are quality doctors. But what is more important, years of direct medical care experience or just having their doctor pass an expensive test every 10 years? With the expected avalanche of patients entering our health care system, does the public want to pay for irrelevant bureaucracy that just feeds the system rather than improving physician availability?. I suspect that the public would rather have their doctors engaged in their care rather than being distracted by unproven testing exercises.
But it seems bureaucrats must endlessly continue the money flow that assures their spousal travel fees, so maintenance of certification will likely soon be tied to the granting of hospital credentials or state licensure. We should ask ourselves if we really want this. In 2011, the ABIM received $44 million in fees from doctors sitting for board certification and maintenance of certification. That's a hefty chunk of change. So much so that at least one doctor has recently sued the ABIM over concerns of monopolizing the process.
Doctors need to speak up, especially when others stand to enrich themselves on the labors of their colleagues. If doctors can't get use a pen from a pharmaceutical rep, they sure as heck shouldn't being using their own colleagues' hard-earned funds for their spouse's travel.
Please think of these things when you cash my latest $775 check, ABIM, will you?
-Wes
Yesterday, I received a $775 bill for my "additional examination fee" from the American Board of Internal Medicine (ABIM) in the mail. I was surprised and had to ask myself, "Why?" Especially since this rate is more expensive than staying at a five-star hotel room in Chicago for a day.
In total, the out-of-pocket expenses for Maintenance of Certification in both of my subspecialties above have been as follows:
Enrollment Fee: Maintenance of Certification: $1840 (this includes only one exam fee)And to think I get to do this every ten years!
Additional Examination Fee: $775.00
ACC Self-Assessment Program (ACCSAP 8): $620
Heart Rhythm Society Board Review Course and ABIM Recertification Module $1440
So far, that's: $4675 just to "maintain" my certification this time around. (Per annum: about $500 per year). (Note that this cost does not count the lost revenue I sustain from leaving my workplace to attend the Board Review Course, to study , or take the tests.)
But when we learn of the salaries of the leadership of the ABIM, it becomes clear why these fees are so high. According to the publically-available IRS Form 990 from 2012 (the last available), ABIM Executive Christine K Cassel received salary and benefits of $786,751 in 2011, plus payments for spousal travel. (At that salary, why are testing physicians picking up travel expenses for Dr. Cassel's husband?)
Equally outrageous has been the ABIM's recent requirement for re-certifying physicians to complete a "Practice Improvement Module" as part of their re-certification requirements. For those unfamiliar, doctors have to find something to improve in their practice, measure how its going, make a change, then measure the effect of that strategy in hopes it will improve patient care. On the surface this requirement seems so, well, nifty! How could anyone argue with the intent of such a requirement? But imagine the time it takes to conceive and execute such a project. How much patient care suffers as a result? So doctors who are already stretched for time look for ways around this requirement and luckily, they find it is easily gamed. So they talk to their hospital's quality coordinator, get some useful data, enter it into the MOC website, then answer questions that ask "what-did-you-learn-as-a-result-of-completing-this-module?" and, presto! Their module is done!
Really, is this useful? Maybe we should include handwashing exercises, too. Or is this more about the ABIM maintaining their leadership's benefits and political favor? As I performed this painful part of my re-certification requirement, I couldn't help but hear echo's of Don Berwick's Institute for Healthcare Improvement's educational curriculum that helped pave the way for the life-long healthcare guartantee he received for himself and his family for life. Could the leadership of the ABIM have similar aspirations for a similar golden parachute?
I can't help but wonder.
As I wrote my additional exam fee check, I also reflected on what the "value" of this re-certification process is for physicians like myself that have been previously certified.
Will doctors get more income for having this certification? No, especially in the current payer climate that seeks to continue to limit physician payments.
Will doctors get more prestige for having this certification? Not really, especially when nurse practitioners at Walgreens can call themselves "board certified," too. (It is interesting to note that their certification only costs $395 - 8.4% of the cost for medical re-certification. Maybe doctors should take their test instead?) What responsibility does the ABIM have to protect the value of the term "board certification" for physicians who invest in this process? Given the ongoing board "certificate" fraud perpetuated by others directly under the nose of the ABIM, we are left to wonder if they have any authority to protect physicians' investment in this process.
Is the time required to re-certify worth it for doctors and patients? Will doctors be smarter for having this certification? I think the ABIM does try to make the knowledge assessment modules relevant to new knowledge in the medical field. (Actually, I found these almost fun to take). But I already stay up to date with current innovations and studies in my field thanks to my teaching responsibilities, ongoing state licensure requirements for continuing medical education credits, and my rather healthy social media presence. Do these costly re-certification tests improve my knowledge significantly enough to affect my patient's outcomes? I honestly don't think I've ever felt so.
Surely the public wants to know their doctors are quality doctors. But what is more important, years of direct medical care experience or just having their doctor pass an expensive test every 10 years? With the expected avalanche of patients entering our health care system, does the public want to pay for irrelevant bureaucracy that just feeds the system rather than improving physician availability?. I suspect that the public would rather have their doctors engaged in their care rather than being distracted by unproven testing exercises.
But it seems bureaucrats must endlessly continue the money flow that assures their spousal travel fees, so maintenance of certification will likely soon be tied to the granting of hospital credentials or state licensure. We should ask ourselves if we really want this. In 2011, the ABIM received $44 million in fees from doctors sitting for board certification and maintenance of certification. That's a hefty chunk of change. So much so that at least one doctor has recently sued the ABIM over concerns of monopolizing the process.
Doctors need to speak up, especially when others stand to enrich themselves on the labors of their colleagues. If doctors can't get use a pen from a pharmaceutical rep, they sure as heck shouldn't being using their own colleagues' hard-earned funds for their spouse's travel.
Please think of these things when you cash my latest $775 check, ABIM, will you?
-Wes
Sunday, July 14, 2013
Case Study: Um, A Post-op Chest X-ray
Radiologist: "Um, doctor, there's something funny on your patient's post-operative chest x-ray:"
(Remember, you never want to hear the word "Um.")
What did the radiologist see?
-Wes
 |
| Post -operative Chest X-ray (Click to enlarge) |
(Remember, you never want to hear the word "Um.")
What did the radiologist see?
-Wes
Saturday, July 13, 2013
The Clash of Cultures
"It looks like you've done very well, Mr. Smith..."
"Thank you, doctor."
He left the patient's room and ambled back to the nurses station, legs tired and ankles somewhat swollen. It had been a long case and now he just had to type his note, send an email message, and review his schedule for the following day. He sat down at the computer and logged in. That's when he looked up briefly and saw them.
They looked so young. Their newly-pressed white coats accentuated the faint glow of the computer screens on their perfect skin. They looked like thoroughbreds, while he the old horse put to pasture, if they had noticed. But they were each staring intently at the electronic screen arranged along the desk countertops, one with his back to the other two. Occasionally the one would turn to ask the other two a question, then return with a blank stare to the screen before him. The new residents had arrived.
"So different," he thought. There they are, seated before a computer looking more like telephone operators rather than doctors. "What were they thinking?" he wondered silently, then pondered how things had changed.
For now he realized that they didn't have to know where the blood or microbiology laboratories were. They didn't have to search for an x-ray. Instead, they had to find which button to click. This day, this moment, was probably their dream come true. For it was the day they had waited and worked so hard for, the day they became a working doctor. Underneath the electronic facade, they were probably excited, eager, wanting to do a good job: excitement and anxiety, all rolled up into one.
But somehow, it was different. The new doctors rarely looked at each other as they stared vacantly into their computer screens. It was as though they were transfixed by medical porn. It looked as though they were being bred into an interchangeable electronic medical documentation team, not a cohesive, personal one equipped with interpersonal skills. After all, they really didn't have to see or listen to each other any more. They could send each other an e-mail, text messages, or chose to stay isolated, listening to the rapid-fire clicking taking place next to them. Emotionally and physically, they could be miles apart or seated together, it really didn't matter any more. It was so efficient, so neat, that their organized orientation to electronic dehumanization required very little movement, very little patient contact.
But young doctors, he realized, were meeting their patients like they've always met new friends on Facebook: electronically first. Was this better? He wasn't sure. Would the initial impressions garnered from the chart skew their ability to look independently and objectively at their patient? Will they be capable of accurate empathy? Will a patient's undocumented concerns be missed? Will new doctors forget to use the subtle signs and symptoms brought forth by the physical exam to head off disaster or just wait for the test results to return before reacting instead? Will they see enough, smell enough, do enough, sweat enough, to learn enough?
He wondered.
But they were young. They could learn. They would learn. They'd adapt.
And they could type faster.
Perhaps. Maybe. We'll see. "I can only hope," he thought, realizing he wasn't getting any younger.
He turned his gaze back to his own screen and clicked the icons slowly, the way he had done hundred of times before, filling his note with voluminous immaterial drivel the government required, then added a single line: "Doing well. Home today." So meaningful, he silently quipped, meaningful indeed.
He rose to say goodbye to the unit clerk, who smiled as she peeled her eyes from her iPhone, "Goodnight, doctor."
"Take care of the new guys, okay?" as he pointed to the people behind her with the new white coats.
"You bet," she said, not turning to see them. Her eyes reset to to her iPhone screen instead.
-Wes
"Thank you, doctor."
He left the patient's room and ambled back to the nurses station, legs tired and ankles somewhat swollen. It had been a long case and now he just had to type his note, send an email message, and review his schedule for the following day. He sat down at the computer and logged in. That's when he looked up briefly and saw them.
They looked so young. Their newly-pressed white coats accentuated the faint glow of the computer screens on their perfect skin. They looked like thoroughbreds, while he the old horse put to pasture, if they had noticed. But they were each staring intently at the electronic screen arranged along the desk countertops, one with his back to the other two. Occasionally the one would turn to ask the other two a question, then return with a blank stare to the screen before him. The new residents had arrived.
"So different," he thought. There they are, seated before a computer looking more like telephone operators rather than doctors. "What were they thinking?" he wondered silently, then pondered how things had changed.
For now he realized that they didn't have to know where the blood or microbiology laboratories were. They didn't have to search for an x-ray. Instead, they had to find which button to click. This day, this moment, was probably their dream come true. For it was the day they had waited and worked so hard for, the day they became a working doctor. Underneath the electronic facade, they were probably excited, eager, wanting to do a good job: excitement and anxiety, all rolled up into one.
But somehow, it was different. The new doctors rarely looked at each other as they stared vacantly into their computer screens. It was as though they were transfixed by medical porn. It looked as though they were being bred into an interchangeable electronic medical documentation team, not a cohesive, personal one equipped with interpersonal skills. After all, they really didn't have to see or listen to each other any more. They could send each other an e-mail, text messages, or chose to stay isolated, listening to the rapid-fire clicking taking place next to them. Emotionally and physically, they could be miles apart or seated together, it really didn't matter any more. It was so efficient, so neat, that their organized orientation to electronic dehumanization required very little movement, very little patient contact.
But young doctors, he realized, were meeting their patients like they've always met new friends on Facebook: electronically first. Was this better? He wasn't sure. Would the initial impressions garnered from the chart skew their ability to look independently and objectively at their patient? Will they be capable of accurate empathy? Will a patient's undocumented concerns be missed? Will new doctors forget to use the subtle signs and symptoms brought forth by the physical exam to head off disaster or just wait for the test results to return before reacting instead? Will they see enough, smell enough, do enough, sweat enough, to learn enough?
He wondered.
But they were young. They could learn. They would learn. They'd adapt.
And they could type faster.
Perhaps. Maybe. We'll see. "I can only hope," he thought, realizing he wasn't getting any younger.
He turned his gaze back to his own screen and clicked the icons slowly, the way he had done hundred of times before, filling his note with voluminous immaterial drivel the government required, then added a single line: "Doing well. Home today." So meaningful, he silently quipped, meaningful indeed.
He rose to say goodbye to the unit clerk, who smiled as she peeled her eyes from her iPhone, "Goodnight, doctor."
"Take care of the new guys, okay?" as he pointed to the people behind her with the new white coats.
"You bet," she said, not turning to see them. Her eyes reset to to her iPhone screen instead.
-Wes
Subscribe to:
Posts (Atom)